‫من‬

ِ ‫ح‬ ْ ‫الر‬َّ ِ‫ِْبسـ ِم اهلل‬

ِ‫الر ِحيم‬
َّ
WOUND INFECTOIN: DIAGNOSIS
AND MANAGEMENT
Sejauh mana lapisan kulit
yang terkena.....???
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INTRODUCTION
 Infection as a significant problem:
Results in increased admission to critical care, length of
hospital stay, cost of care, and death (Fleischmann et al,
2003; Kirkland et al, 1999).
Osteomyelitis may occur and increase the patient’s risk of
bacteremia, sepsis, and multisystem organ failure
(Bonham, 2001)
 Acute and chronic wounds are both at risk of infection.
 Amputation may be needed because of uncontrolled
infection in the lower extremities of persons with diabetes.
 BIOBURDEN

 The presence of
bacteria in the wound
creates a burden on
the wound healing
process
 This burden is due to
the fact that bacteria
compete for the limited
supply of oxygen and
nutriens in the wound.
 MICROBIAL STATES OF A WOUND

1. Contamination
Contamination is the presence of nonreplicating
microorganisms on the wound surface.
Arise from normal flora (e.g skin, periwound),
external environment (e.g bed linen, devices), and
endogenous source (e.g feces, urine)
2. Colonization
Presence of replicating bacteria without a host
reaction or clinical signs and symptoms of
infection.
Bacteria in this phase are not pathogenic and do
not necessitate treatment with systemic or local
antibiotics.
3. Critical Colonization
Critical colonization is a term recently coined to
describe a wound that is arrested in healing as a
result of the bioburden (Bowler, Duerden and
Amstrong, 2001 ; Edwards and Harding, 2004 ;
Sibbald et al, 2001).
During the critical colonization state, organisms
remain on the surface of the wound and have not
yet invaded the soft tissue.
Systemic response to the microbial load (fever or
leukocytosis) is not present.
Cont…..
Visually, granulation tissue may not appear
healthy (the wound appear clean but not granular).
Important indicators of this phase
Must be identified so that progression to infection
can be prevented through appropriate use of
topical antimicrobials.
4. Infection
Infection is present when microorganisms invade
tissues and there is a systemic response to them
(Edwards and Harding, 2004 ; Mangram et al,
1999 ; Robson, 1997).
Infected acute wounds usually demonstrate signs
of local inflammation and pus formation or
increased exudates.
When cultured, infection in acute wounds is
diagnosed by the presence of 105 microorganisms
per gram of tissue or greater, or the presence of
any level of β-hemolytic streptococcus (Falanga,
2004 ; Mangram et al, 1999 ; Robson, 1997)
Conti………….
Infection in chronic wounds is often subtle, as
seen in change in the exudate, increased pain,
and delayed healing (Bowler, Duerden, and
Amrstrong, 2001 ; Edwards and Harding, 2004 ;
Gardner et al, 2001).
Chronic wounds are usually polymicrobial and
characrized by high levels of resident bacteria.
Gram-negative bacteria : unusual odor, fever,
leukocytosis.
Conti………….
Culture results for chronic wound infections show
more than 105 organisms per grams of tissue, or
as few as 103 organisms/gram of tissue if a virulent
organism such as β-hemolytic streptococcus is
present (Edwards and Harding, 2004 ; Robson,
1997).
 RISK FACTORS
FOR SURGICAL SITE INFECTION
Risk Factors Smith et Kompatscher Malone et Barie, Mangram
al, 2004 et al, 2003 al, 2002 2002 et al, 1999
Obesity X X X
Intraoperative hypotension X
Surgery longer than 2 hours X
Diabetes mellitus X X X
Malnutrition X X X
Low hematocrit X X
Ascites X X
Steroid use X
Age extremes X X
Remote infection X X
Chronic inflammation X X
Hypercholesteremia X
Hypoxemia X
Peripheral vascular disease X
Prior site radiation X
Recent operation X
Skin carrier of Staphylococcus X
Skin disease in area X
Nicotine use X
Perioperative Blood Products X
 Signs and Symtoms of Infection
in Chronic Wound
 New/ increase slough
 Drainage excess, change in color/ consistency
 Poor granulation tissue – friable, bright red,
exuberant.
 Redness, warmth around the wound
 Sudden high glucose in patient with diabetes
 Pain and tenderness
 Unusual odor
 Increased wound size/new areas of breakdown
FACTORS THAT EFFECT THE MICROBIAL STATE
OF A CHRONIC WOUND

 Host defenses
 Microorganisms’ defenses
 Toxin
 Adherence of the microorganism
 Invasive factors
 Environmental factors
 DIAGNOSIS OF INFECTON

 History
 PhysicalExamination
 Laboratory test
 Complete Blood Count (CBC)
 Wound Cultures
Clinical Indication for a Wound Culture

 Local sign of infection: pus, change in odor or

character of axudates, redness, induration,
change in wound odor
 Systemic signs of infection: fever,
leukocytosis
 Suddenly elevated glocose
 Pain in neuropahic extremity
 Lack of healing after 2 weeks in a cleas wound
despite optimal care
Tips on Wound Culturing
 Obtain the culture before administering antibiotics
 Obtain the culture from clean tissue
 Collect the specimen using sterile technique
 Do not contaminate the specimen when placing it in the
container.
 Collect sufficient specimen for examination
 If a Gram stain will be done, obtain enough specimen
 Place the specimen in an appropriate container
 Complete the laboratory slip to provide clinical data for the
microbiologist
 Transport quickly to the laboratory to keep the organisms
viable
 Topical Antimicrobial lndication
Agent Vehicle Staph. Strepto Pseudomo Comments
Aureus coccus nas
f Cadaxomer Iodine Yellow-brown MRSA Releases iodine slowly, less toxic
powder/paste/ ˅ ˅ ˅ to granulating tissue; broad
oinment spectrum, including virus and
fungus.
Gentamicin sulphate Alcohol cream based or ˅ ˅ ˅ Good broad spectrum vs gram
cream/ointment petrolateum oinment negatives
f Metronidazole Wax-glycerin cream and Good choice for MRSA; Excellent
gel/cream carbogel - - - topical penetration
940/propyleneglycol gel
f Polymixin B sulphate- Cream MRSA Broad spectrum; low cost; oinment
Gramcidin ˅ ˅ ˅ contains bacitracin, a new
sensitizer
f Mupuricin 2% Propyleneglycol oinment MRSA Good choice for MRSA ; excellent
cream/oinment ˅ ˅ - topical penetration
Polymyxin B Sulphate- Ointment ˅ ˅ ˅ Neomycin is a potent sensitizer and
Bacitracin zinc- may crossreact, in 40% of cases, to
neomycin* aminoglycosides
f Silver Sulvadiazine Water-miscible cream MRSA Do not use in self-sensitive
˅ ˅ ˅ individuals
f Silver (Ionozed) Absorbent bilayered sheet, MRSA Ionized silver is activated with
burn dressing, aldinate, ˅ ˅ ˅ sterile water. Saline will precipitate
foam and other forms the silver chloride

Source: Fowler et al, 2003 MRSA: Methicillin-resistant Stap. Aureus

* Contain common sensitizer f : preferred products
 LOCAL TREATMENT OF WOUND INFECTION
 Cleansing
 Debridement
 Topical Therapy
 Additional Treatments

SYSTEMIC TREATMENT OF WOUND INFECTION

 Antibiotic
 Oxygen
 Nutrition and Fluid

PSYCOLOGICAL SUPPORT AND EDUCATION

TERIMA KASIH